Post on 14-Apr-2018
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Liver Cirrhosis
Nikko G. MelencionAheh
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Introduct ion Cirrhosis is a complication of many liver diseases that is
characterized by abnormal structure and function of the liver.The diseases that lead to cirrhosis do so because they injure
and kill liver cells, and the inflammation and repair that is
associated with the dying liver cells causes scar tissue to
form. The liver cells that do not die multiply in an attempt toreplace the cells that have died.
This results in clusters of newly-formed liver cells
(regenerative nodules) within the scar tissue. There are many
causes of cirrhosis; they include chemicals (such as alcohol,fat, and certain medications), viruses, toxic metals (such as
iron and copper that accumulate in the liver as a result of
genetic diseases), and autoimmune liver disease in which the
body's immune system attacks the liver.
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SYMPTOMS Loss of appetite
Lack of energy (fatigue), which may be debilitating
Weight loss or sudden weight gain
Bruises
Yellowing of skin or the whites of eyes (jaundice) Itchy skin
Fluid retention (edema) and swelling in the ankles, legs,and abdomen (often an early sign)
A brownish or orange tint to the urine
Light colored stools Confusion, disorientation, personality changes
Blood in the stool
Fever
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RISK FACTORS Alcohilism
Malnutrition
Infection Drug Fibrosis
Scarring
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PATIENTS DATA
NAME: X
GENDER: Female
Birth Place: Atimonan,QuezonAge:81 yrs.old
Chief Complain: Edematous for 1 month with
difficulty of breathingAdmitting Diagnosis:Dr. Daquilanea
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PHYSICAL ASSESSMENT
HEAD
symmetric
proportionate to body size
HAIR
Black in color thin and fine.
EYES
White sclera
dark brown pupil
FACE
normal lining of the nose
EYES AND EARS
pinkish lips and not dry
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CHEST/THORAX
w/ respiratory distress
ABDOMEN Non-tender abdomen
no signs of abnormal sounds upon auscultation
not bloated SKIN
skin is warm to touch
no rashes or dryness noted
CARDIOVASCULAR SYSTEM heart rate within abnormal range
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Lower extremities
Knees, leg, feet and toe
With lesions With active range of motion
MUSCULO SKELETAL SYSTE
joint and muscle are not in pain
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LABORATORYRESULTS
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TEST RESULT REFERENCE
WBC Count 10.3x10 4-10x10
DIFFERENTIAL COUNT
Neutrophils .84 .55-.65
Lymphocytes .13 .25-35
Monocytes .01 .01-.03
Eusinophlls .02 .02-.04
RBC Count 3.88x10 4.0-5.4x10
Hemoglobin 102 120-160g/lHematocrit .35vol% .36-.46vol%
COMPLETE BLOOD COUNT
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TEST RESULT REFERENCE
FBS 219 70-105
Cholesterol 232.2 60
LDL 151.38
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ANATOMY ANDPHYSIOLOGY ANATOMY AND PHYSIOLOGY
The liver is the largest internal organ in the body, and weighs about 3 pounds in an adult. The
liver is located in the right upper quadrant of the abdomen, just below the diaphragm. A thick
capsule of connective tissue called Glisson's capsule covers the entire surface of the liver. The
liver is divided into a large right lobe and a smaller left lobe. The falciform ligament divides
the two lobes of the liver. Each lobe is further divided into lobules that are approximately 2
mm high and 1mm in circumference. These hepatic lobules are the functioning units of theliver. Each of the approximately 1 million lobules consists of a hexagonal row of hepatic cells
called hepatocytes. The hepatocytes secrete bile into the bile channels and also perform a
variety of metabolic functions. Between each row of hepatocytes are small cavities called
sinusoids. Each sinusoid is lined with Kupffer cells, phagocytic cells that remove amino acids,
nutrients, sugar, old red blood cells, bacteria and debris from the blood that flows through the
sinusoids. The main functions of the sinusoids are to destroy old or defective red blood cells,to remove bacteria and foreign particles from the blood, and to detoxify toxins and other
harmful substances. Approximately 1500 ml of blood enters the liver each minute, making it
one of the most vascular organs in the body. Seventy-five percent of the blood flowing to the
liver comes through the portal vein; the remaining 25% is oxygenated blood that is carried by
the hepatic artery.
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Functions of the Liver:
Bile production and excretion
Excretion of bilirubin, cholesterol, hormones, and drugs
Metabolism of fats, proteins, and carbohydrates
Enzyme activation
Storage of glycogen, vitamins, and minerals
Synthesis of plasma proteins, such as albumin and globulin, and clottingfactors
Blood detoxification and purification
A. liver B. hepatic vein C. hepatic artery D. portal vein E. common bileduct F. stomach G. cystic duct Gallbladder
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PATHOPHYSIOLOGY
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Predisposing Factors:
-Heredity
-Metabolic Disorders
(Iron overload, Glycogen,
Storage disease, Wilsons
diseases)
-Underlying condition (
hepatitis, fatty liver, liver
tumor, etc. )
-Females are more pronethan males but reports
have higher cases in
males
-Highly civilized
countries
Precipitating Factors:
-Alcoholic ( long term
ingestion of at least
80g/day of ethanol)
Female 20g/day
-Poor diet
-Diet high in fat/ low in
protein
-Obesity
Predisposing Factors:
-Heredity
-Metabolic Disorders (Iron
overload, Glycogen,
Storage disease, Wilsons
diseases)
-Underlying condition (
hepatitis, fatty liver, liver
tumor, etc. )-Females are more prone
than males but reports have
higher cases in males
-Highly civilized countries
Precipitating Factors:
-Alcoholic ( long term
ingestion of at least
80g/day of ethanol)
Female 20g/day
-Poor diet
-Diet high in fat/ low inprotein
-Obesity
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Increased liver synthesis of triglycerides and fatty acids, reduction in oxidation of the
fatty acids, and decreased release of lipoprotrein
Fat accumulation in the parenchymal cells of liver and distention of cytoplasm with
fats
Liver Steatosis/ Fatty liver
Hepatocytes degenerate and become infiltrated with leukocytes and lymphocytes,
now called as Mallorys bodies or alcoholic hyalin
Mallory bodies may result to fibrosis of its surrounding cells and veins
Inflammation of the Liver
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Alcoholic hyalin leads to a hardened hyalin by which nechrosis may occur
Progressive hepatocytes destruction leads to early scar formation and further damage
to liver parenchyma
Liver capsule become firm and formation of regenerative nodules happenns
ALCOHOLIC CIRRHOSIS
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DOCTORS ORDER
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Doctors Order Medical Intervention Nursing
Responsibility
Sept. 25 2013 Please admit to female
ward
>Client was admitted
for further care and
management.
Admisson of patient
Route TPR >This serves as basis
for initial v/s
>Assess and get pt.s
initiial v/s
Low Salt Low FatDiet
>To decreased thecholesterol
>to inform thedietrician and SO
CBC,
Urinalysis,BUN,Creati
nine
>Baseline lab test for
diagnosis
>Obtain request
form,specimen and
refer to the lab for the
test.
0.9 PNNS 1L to drop
30 ghs
>useful for daily
maintenance of body
fluids and nutrtion
and for rehydration.
>to regulate IVF as
desired.
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Sept. 26, 2013 Hydrochlorothizide heart failure in pt.
who cannot to
elevate ACE
inhibitors
>To administer initial
dose and note iin
med sheet.
Digoxin
Increased Digoxin 0.2
mg 1 tab am
Continue meds tab
pm
>to continue
treatment regimen
>to continue the
right meds
Sept. 27, 2013 For Ultrasound whole
abdomen 0.9 PNSS 1Lto KVO
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NURSING CAREPLAN
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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Objective:
>Tachycardia
>Shortness
of breath
>Cool,clammyskin
>Increased blo
od pressure
>BP=150/90.
mmHg
Hypertension After 8 hrs
of nursinginte
rventions, blo
od pressure
will bewithinset parameter
s for theclient
1. monitor VS
atleast q 1-2
hrs and prn.
2. encourage
patienttodecrease
intake
of caffeine,
cola
andchocolates.
3. administer vao
activedrugsand
titrate
asordered to
maintain press
ures at
set parameters
for patient.
4. observe
for complaints
of blurred
vision,tinnitus
or confusion.
1. Tomonitor bas
eline data.
2. caffeine is
acardiac
stimulantandmay
adverselyaffec
t
cardiacfunctio
n.
3. these frugs
haverapidaction andmay
decrease
the blood
pressure
toorapidly,
resulting
incomplication
s
4. may
indicatecyanid
e toxicityfrom
increasingintra
cranial pressure
After 8 hrs
of nursinginte
rventions, blo
od pressure
maintainedwithin
set parameter
s for
theclient.Goal
was met
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5. monitor I&Ostatus
6. Observe extremities
for swelling,
erythema,tenderness and
pain.Observefor decreased
peripheral pulses, pallor,
coldness and cyanosis
7. instruct client in signs/
symptoms to report to
physician such asheadache upon rising,
increased blood pressure,
chest pain shortness of
breath,increased heart
rate
5. I&O will give anindication
offluic balance
or imbalance thus
allowing for changes
intreatment regimenwhenrequired
6. Bedrest promotesvenous
statis whichcan increase
the risk of
thromboembolus
formation. If treatment istoo rapid and aggressivein
decreasing the blood
pressire,tissue perfusion
will be impaired
andischemia can result
7. promote sknowledge andcompliance with
treatment.
Promotes prompt
detection and
facilitates prompt
intervention
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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
>weakness
>Abnormal
heart rate or
BP response
to activityExertional
>discomfort
or dyspnea
Activity
Intolerance
related to
generalized
weakness
After 8
hours of
nursing
intervention
the clientwill able to
move her
body or
extremities
1. Assess the
patients
response to
activity, noting
pulse rate morethan 20
beats/min faster
than resting
rate; marked
increase in BP
during/afteractivity (systolic
pressure
increase of 40
mm Hg or
diastolic
pressure
increase of 20mm Hg);
dyspnea or chest
pain; excessive
fatigue and
weakness;
diaphoresis;
dizziness.
1. The stated
parameters
are helpful
in
assessingphysiologic
al
responses
to the
stress of
activityand, if
present,
are
indicators
of
overexertio
n.
After 8 hours
of nursing
intervention
the client w
sable to moveher body or
extremities.
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2. Establish guidelines
and goals of activity
with the clients and
caregiver.
3. Anticipate the
clients need.
4. Encourageverbalization of
feelings regarding
limitations.
2. Motivation is
enhanced if the client
participates in goal
setting. Depending on
the etiological factors
of activity intolerance,
some clients may be
able to live
independently and
work outside the
home. Other clientswith chronic
debilitating disease
may remain.
3. This reduces risk for
falling while reaching.
4. Acknowledgment thatliving with activity
intolerance is both
physically and
emotionally difficult
aids coping.
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5. Encourage active
ROM exercises. If
further
reconditioning isneeded, confer with
rehabilitation
personnel.
6. Teach ROM and
strengthening
exercises.
7. Change position
often.
5. Exercise
maintains muscle
strength.
6. Exercisepromotes
increased venous
return, prevents
contractures, and
maintain /
increases muscle
strength
7. This distributes
work to different
muscles to avoid
fatigue.
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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Objecive:
- NGT
Feeding
- Impaired
Swallowing- Glasgow
Coma Scale
of 2/13
- Severe body
weakness
Risk for
Aspiration
related to
impaired
swallowingsecondary
to
nasogastric
tube
feeding
After 8 hours
of nursing
intervention
my patient
had reducedrisk for
aspiration as
evidenced by:
>patent
nasogastric
tubing
>toleratenasogastric
tube feeding
>patent
airway
>active gag
reflex
1. Monitor
level of
consciousne
ss.
2. Assesscough and
gag reflexes.
3. Auscultate
bowel
sounds to
evaluate
bowelmotility and
assess for
abdominal
distention
and
firmness
4. Assess
pulmonary
status for
clinical
evidence of
aspiration.
1. decreased level of
consciousness is a
prime risk factor
for aspiration.
2. A depressedcough or gag
reflex increases
the risk for
aspiration
3. Decreased
gastrointestinal
motility increasesthe risk of
aspiration because
food or fluids
accumulate in the
stomach.
4. Aspiration of
small amounts can
occur without
coughing,
especially in
patients with a
decreased level of
consciousness
After 8
hours span
of care,
patient hadreduced
risk for
aspiration
as
evidenced
by:>patent
nasogastric
tubing
>tolerate
nasogastric
tubefeeding
>patent
airway
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5. Keep suction setup
available and use as
needed.
6. Position patient
with a decreasedlevel of
consciousness on
their side.
7. Provide oral care
after meals.
8. Instruct watchers on
signs and symptoms
of aspiration.
5. This is necessary to
maintain a patent
airway.
6. This decreases the
risk for aspiration bypromoting drainage
of secretions away
from the airway.
7. This removes
residual food that
can be aspirated at alater time
8. Aids in appropriate
assessment of high-
risk situation and
determination of
when to call forfurther evaluation.
ASSESSMENT DIAGNOSIS PLANNI NG INTERVENTIIION RATIONALE EVALUATION
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ASSESSMENT DIAGNOSIS PLANNI NG INTERVENTIIION RATIONALE EVALUATION
>Speech
abnormalities
>changes in
pupillary
reactions;>extremity
weakness or
paralysis;
>altered
mental
status;
>difficult in
swallowing;
>changes in
motor
response;
>behavioral
changes
Alteration in
tissue
perfusion
(cerebral)
related tointerruption in
cerebral blood
flow.
After 8 hours
of nursing
interventon
the patients
interruptionin blood flow
decrease.
1. Note
customarybas
eline data
2. Review result
of diagnosticstudy
3. Note history
of syncope,br
ief/intermitte
ntperiods
of confusion
4. Instruct in
bloodpressur
emonitoring
athome,
advicepurcha
se of
homemonitoringequipment
refer
tocommunity
resources
asindicated
1. providecom
parison
withcurrent
findings
2. Todeterminel
ocation/sev
erity
of condition
3. Suggestive
of transient
ischemicatt
ack
4. Facilitatema
nagement
of hyperten
sion,which
is amajor risk
factor
for damage
bloodvessel
s/organfunc
tion
After 8 hours
of nursing
interventon
the patients
interruptionin blood flow
decreased.
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6. Elevate HOB
7. Administer med
ication
8. Assist with
monitor hypoth
ermia therapy
9. Recommend
with physicalrehabilitation
therapy
6. To promote
circulation/
venous drainage
7. To promote
pharmacologic
regimen
8. Which may be
used todecreases
metabolic and
O2needs.
9. To have contact
with other
healthcareprovider
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DRUG STUDY
THERAPEUTIC ACTION CONTRAINDIC TOXIC/SIDE INTERVENTIIO SAFE DOSE
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THERAPEUTIC
EFFECT
ACTION CONTRAINDIC
ATION
TOXIC/SIDE
EFFECT
INTERVENTIIO
N
SAFE DOSE
Cefazolin
Anti-biotic
Cephalosporin
Anti-infectives
Susceptible
bacterial
infections
includingsepticemia,
respiratory,
biliary or GU
tract, skin and
skin structure,
bone and
joint,
endocarditis.
Surgical
prophylaxis.
Hypersensitiv
ity to
cephalospori
ns
CNS:
Seizures (high
doses)
GI:Pseudomembran
ous colitis,
diarrhea,
nausea,
vomiting,
cramps
GU:
Interstitial
nephritis
DERM:
Rashes, urticaria
HEMAT:
Blood dyscrasias,hemolytic
anemia
LOCAL:
Pain at IM site,
phlebitis at IV
site
> Assess
patient for
infection at
beginningand during
therapy.
>observe
patient for
signs and
symptoms of
anaphylaxis
>Monitor site
for
thrombophle
bitis . Change
sites every
48-72 hr to
prevent
phlebitis.
Pneumococcal
pneumonia:
500mg every
12 hours. Mildinfections:
250500mg
every 8 hours;
moderate to
severe
infections:
500mg1g
every 68
hours. Severe,
life-
threatening
infections (eg,
endocarditis,septicemia): 1
1.5g every 6
hours; max
12g/day. UTIs:
1g every 12
hours.
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THERAPEUTIC
EFFECT
ACTION CONTRAINDICA
TION
TOXIC/SIDE
EFFECTS
INTERVENTION SAFE DOSE
Furosemide
Loop
diuretic
Inhibits there
absorption of
sodium and
chloride from the
loop of henle and
distal renal
tubule.
Hypersensitivity nausea
andvomiting,hea
dache,dizziness,
fatigue,diarrhea,
dyspepsia,abdo
minal
pain,anorexia
BLACK BOX
WARNING:
Profound
diuresis with
water and
electrolyte
depletion can
occur; careful
medical
supervision is
required.
Administer
with food or
milk to
prevent GIupset.
Reduce
dosage if
given with
other
antihypertensives; readjust
20,40,80, mg OD
THERAPEUTIC ACTION CONTRAINDICAT TOXIC/SIDE EFFECT INTERVENTION SAFE DOSE
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THERAPEUTIC
EFFECT
ACTION CONTRAINDICAT
ION
TOXIC/SIDE EFFECT INTERVENTION SAFE DOSE
CAPTOPRIL
Anti-hypertensive
ACE inhibitors
Blocks ACE from
converting
angiotensin I to
angiotensin II, a
powerfulvasoconstrictor,
leading to
decreased blood
pressure,
decreased
aldosterone
secretion, a
small increase in
serum
potassium
levels,
and sodium and
fluid loss;
increased
prostaglandinsynthesis also
may be involved
in the
antihypertensiv
e
action.
Contraindicat
ed with
allergy to
captopril,history of
angiodema.
Use
cautiously
with
impairedrenal
function;
CHF; salt or
volume
depletion,
lactation,pregnancy.
CV:Tachy
cardia, angina
pectoris, MI,
Dermatologic: Rash,dermatitis,
photosensitivity,
alopecia
GI: Gastric
irritation, aphthous
ulcers, peptic
ulcers, jaundice,
injury, anorexia,
constipation
GU: Proteinuri
a, renal
insufficiency, renal
failure
Hematologic: hemolytic anemia,
pancytopeniaOther:
Cough, malaise, dry
mouth,
Administer 1
hr before or 2
hr after
meals.
>montor for drop
of BP
>reduce dosage
in patients with
impaired renalfunction
Tab:
12.5 mg
25mg
50mg
100mg
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THERAPEUTIC
EFFECT
ACTION CONTRAINDICATI
ON
TOXIC/SIDE
EFFECTS
INTERVENTION SAFE DOSE
Digoxin
Cardiac Drugs
Management of
supra ventricular
arrythimias
particularly atrialfibrillation and
heart failure
Hypertonic
obstructive
cardionyopathy
Nausea,
Vommiting,
anorexia, head
ache, facial pain,fatique,
weakness,dizzine
s,drowsiness,
These drugs may
generally be
taken without
regard to mealstaking your
medication after
a high fiber meal
reduces the
amount of drug
absorbed into
your blood
500mg tab
THERAPEUTIC ACTION CONTRAINDICATI TOXIC/SIDE INTERVENTION SAFE DOSE
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THERAPEUTIC
EFFECT
ACTION CONTRAINDICATI
ON
TOXIC/SIDE
EFFECTS
INTERVENTION SAFE DOSE
Hydrochlorothizid
e
Angiotensin
Heart failure in
pt. who cannot to
elevate ACE
INHIBITORS anddiabetic
nephropathy
Pregnancy Dizziness, head
ache,fatique,back
pain,infection
Good with or
without food
Dosage:
50mg 1 tab OD
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M Medication -Furosemide 1 amp slow IV Push OD
-Captopril 1 tab OD
-Hydrochlorothiazide 25 mg-Digoxin 0.2 mg
-Cefazoline 500 mg
E Environment -Ensure safety precautions outside and inside of the
house
-Keep patient away from materials or equipments that
may harm her.
-Remove everything that may cause injury.
T Treatment -Follow up check-up after 1 week .
H Healh teaching -Provide adequate knowledge regarding Liver Cirrhosis
-Encourage SO to give medication at home on the rght
time and right dose-Instructed SO to be with the patient anytime.
Instruct the patient to report any deterioration in
neurological status to the physician
-Avoid drinking of alcohol
O Ob ti P ti t till it h i
DICHARGE PLANNING